Professional Documents
Culture Documents
Section A
This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks to
describe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authors
and may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines and
laws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked to
illustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2012. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited and
the use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Sondheimer A, Rey JM. Ethics and international child and adolescent psychiatry. In Rey JM (ed), IACAPAP
e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied
Professions 2012.
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I
n a thoughtful and deliberate move, the opening chapter of the first IACAPAP “Of moral purpose
textbook of child and adolescent mental health focuses on the relationship I see no trace in
between ethics and the field. While this chapter focuses on medical practitioners, Nature. That is an
article of exclusively
most of the ethical issues discussed apply to all mental health professionals (e.g.,
human manufacture –
psychologists, social workers, nursing personnel, therapists) treating children and and very much to our
adolescents. Unless otherwise specified, “child” is used to mean all people younger credit”
than 18 years, “parent” represents parents and guardians, “child psychiatrist” means Thomas Huxley
child and adolescent psychiatrists, and “child psychiatry” means the discipline of
child and adolescent psychiatry.
Child psychiatry is a subspecialty of psychiatry, and psychiatry is a medical
specialty. The profession of medicine is intrinsically designed to do battle with
whatever ails the human body and mind, and it attracts practitioners who are so
inclined. If one were to define ethics as that intellectual line of inquiry focusing
on the rightness and wrongness of human behaviors (American Heritage New
Dictionary of Cultural Literacy, 2005) then medicine is an exemplar among the
professions in that, as a vocation devoted to benefitting both the individual and
collective human condition, it is founded and based on trying to do “the right
thing”. Thus, the medical profession and its practice seem clearly based on an
ethical perspective. If only, however, matters could be viewed so simply. In fact,
the study of ethics most commonly focuses on the complexities of the human
condition which, by definition and experience, is usually composed of gray,
complicated and murky areas. Only rarely does an ethical inquiry seem to offer Thomas Henry Huxley
(1825-1895) by Carlo
stark black and white contrasts. That makes the examination of ethical questions Pellegrini ("Ape") 1759-1840.
interesting. Dibner Library, Smithsonian
Institution.
Psychiatry, more than any of the other medical specialties, attempts to focus
equally on mind and body (Slavney, 1993). Ideally the specialty strives to integrate
the two, as their functions are both mediated by the brain. Thus, psychiatry’s
perspective embraces the individual patient’s cognitive, affective, interpersonal
and behavioral processes, while simultaneously functioning in familial, social,
cultural, economic, religious, educational and political contexts. Child psychiatry,
a subspecialty of general psychiatry, focuses on individuals spanning the ages of
infancy through adolescence, with many practitioners extending that range through
young adulthood. The development of the child implies growth and maturation
in various spheres, including the physical body, cognitions, affects, behaviors, and
abilities to judge situations. Insofar as children have not as yet attained adult
capacities in these areas, they require the protection and nurturance of guardians.
In the main parents fill that role, but at other times familial relatives, government
agencies, or other designated individuals provide the settings for youngsters to
mature. Unlike their counterparts who limit their work to the treatment of adult
patients, child psychiatrists usually devote their efforts not only to the youngsters
but to the caregiving adults as well, who often provide information that the child
is unable or unwilling to do. Working with two generations and their interactions,
however, often provides witness to mutual conflicts which, in turn, can trigger
ethical dilemmas.
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would be universalizable, i.e., arrived at independent of the circumstances in “I think we ought always
which they emerge and thus applicable in all contexts. Secondly, these objective to entertain our opinions
“universalist” resolutions would trump personal and group motivations. with some measure of
doubt. I shouldn’t wish
But, in fact, are these assertions axiomatic? In order to arrive at a well- people dogmatically to
reasoned and just resolution, in contrast to the judicious or prudent one, can believe any philosophy,
one legitimately ignore context, be it political, economic, cultural or religious? not even mine”
On the face of it, that would seem unlikely. When contrasting, for example, the Bertrand Russell
environments in which citizens of technologically-advanced democracies live with
those of poverty-ridden, war-dominated, totalitarian autocracies, it is difficult to
imagine applying identical ethical reasoning approaches in both settings and arriving
at identical resolutions. Adding to the confusion are countries that have mixes of
these elements, e.g., those whose current economic development may outstrip that
of the established industrialized democracies but whose political architectures are
largely dominated by “top down” perspectives. Stark examples of contrasts facing
child psychiatrists serve to illustrate this: the luxury of the ethical dilemma of
whether to prescribe a proprietary medication rather than a generic one, when for-
profit insurance companies or government-approved formularies bring pressure on
the child psychiatrist to prescribe the latter, contrasting with a child psychiatrist’s
desire to prescribe an antidepressant – any antidepressant – in a country that
lacks many basic necessities, not to mention an adequate supply of psychotropic
medications; the ethics of resisting the subtle pressure of a prosecutor’s office to
“waive” a juvenile offender’s family court case to adult criminal court versus the Bertrand Russell (1872-
threat from a government’s military arm of a child psychiatrist’s loss of livelihood, 1970)
or worse, should a child psychiatrist refuse to admit a psychiatrically healthy andsuchandsuch
individual, who has run afoul of political or police officialdom, for treatment to
a psychiatric hospital (LaFraniere & Levin, 2010); the ethics of providing care to
a recently bereaved child, surrounded by loving relatives with adequate or better
financial resources, versus the provision of care to orphans, whose parents and adult
relatives were murdered by a warring faction, now sheltered and living together in
a youth dormitory (Stover et al, 2007; Williamson et al, 1987).
Writing about the ethics of child psychiatry with an international
perspective means considering an enormous range of administrative, political,
religious, cultural and economic contexts (Leckman & Leventhal, 2008). Do
these stark differences in turn imply that ethical reasoning should be approached
differently depending on context? In theory, the answer is no. It would appear
that identical reasoning methods ought to be used in all contexts. The settings, It would appear that
however, most definitely need to be considered in the attempt to arrive at the most identical reasoning
methods ought to be
useful resolutions, and those considerations might well result in contrasting final used in all contexts. The
choices in seemingly similar cases. settings, however, most
definitely need to be
HISTORY OF CHILDHOOD considered in the attempt
to arrive at the most useful
Optimal development of children is crucial to all societies, as the offspring resolutions, and those
will become the societies’ adults who, they hope, will carry on the groups’ traditions considerations might well
and values. According to predominating views of Western history, after infancy, result in contrasting final
choices in seemingly similar
children were viewed for millennia as little adults (Aries,1962; DeMause, 1974). cases.
They were considered the property of their parents who, in return for providing
the youngsters with food and shelter, were entitled to the proceeds of their labor.
Inklings of the need for education, beyond that of vocational apprenticeships,
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began to be felt during the 17th century. Accompanying that development, “Ethics is knowing the
conceptualization of childhood as a stage of human development separate from difference between
that of adulthood began to emerge. During the past 100+ years, concentration on what you have a right
to do and what is right
childhood as a unique developmental stage has proceeded apace. During this time to do”
laws have been established mandating school attendance, protecting against child
Potter Stewart
labor, facilitating and supporting the functioning and health of families, creating
juvenile justice systems with unique approaches to legal procedures, and mandating
reports of the abuse and/or neglect of children to governmental authorities (Enzer,
1985; Graham, 1999). As governments progressively took on responsibilities
for children’s welfare, the medical profession similarly evolved. Pediatrics first
appeared as a specialty in the late 1800s; child psychiatry, as a subspecialty of
psychiatry, began to emerge in the 1930s/40s (Musto, 2007). In the USA, the
American Academy of Child Psychiatry was founded in 1953. During the past
half-century, childhood itself has been subdivided more narrowly, while expanding
its purview to now include the stages of infancy, toddlerhood, preschool, school-
Potter Stewart (1915-1985)
age, and adolescence (this last time frame further subdivided into early, middle and was an Associate Justice of
late stages). Thus, the conception of childhood has evolved over time from that of the US Supreme Court
a relatively undifferentiated mass to the current one of substantial differentiation,
distinguished by narrow age spans and differing needs and abilities. While all
the stages share in common the requirement for adult-supplied nurturance, these
fine-tuned differences, as will be seen later, often play a significant role in ethical
considerations.
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CODES OF ETHICS
Throughout the millennia of existence, all human societies have designated
certain citizens as its healers. More recently, these individuals were titled its
physicians, or doctors. Throughout these many centuries, the medical practitioners,
inhabitants of disparate societies situated in countries encompassing the entire
globe, have created innumerable codes of ethics to guide their professional
behaviors. The vast majority of these codes, despite emanating from societies
differing starkly from each other along ethnic, religious and geographic lines, share
common foci and concerns. Thus, the following principles are addressed in most
of the codes:
• Primacy of respect for human life
• Physician responsibility for the well-being of the patient
• Admonition to help or, at least, do no harm; and
• An emphasis on virtue and duty.
Attention is often directed as well toward these specific issues:
• Equality of care independent of the patient’s financial standing
• Expectation of setting appropriate fees
• Employment of legitimate methods to establish diagnoses, including
clinical observation and sound reasoning
• Consideration of whether, and when, to provide treatment; if treatment,
the employment of legitimate therapies
• The confidential nature of the patient-physician relationship
• Prohibition against sexual relationship between physician and patient;
and
• Imposition of punishment or sanctions in the event of inept technical
performance or code violation.
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and the expectation that sound treatments must be based on valid diagnoses,
following the patient’s receipt of complete pertinent information and subsequent
provision of uncoerced consent. In 1989, the United Nations Convention on the
Rights of the Child, with the collective weight of the member countries behind
them, established the rights of children to survival, development, protection
and participation, including the rights to voice their views freely, be given
commensurate deference, and live with their families (United Nations, Centre for
Human Rights, 1990) (see Chapter J.7). The United Nations Convention on the
Rights of Persons with Disabilities (2006) emphasizes that respect and dignity are
to be accorded to disabled individuals of all ages, including children, and embraces
the psychiatrically ill, among many others (United Nations, 2007; Stein et al,
2009). The document highlights nondiscrimination and equal access to health
care, and emphasizes the right of all disabled individuals to equal inclusion in all
aspects of life and its fundamental freedoms. Despite the impressive provenance
of these declarations, it is obvious that their implementation varies enormously
among the signatory countries. That is to be expected, given grossly differing
systems of government. Reassurance, however, comes from the continuing global
ethically-based thrust in the direction of greater protections for children and
the disabled, and an increased awareness of forces that promote or impede their
implementation. In 2006, the International Association for Child and Adolescent
Psychiatry and Allied Professions (IACAPAP) created guidelines and principles
for practitioners in its document entitled Ethics in Child and Adolescent Mental
Health, which in turn derived from IACAPAP’s resolution “Assuring Mental
Health for Children”, promulgated in 1992 and further revised in 1996 and
2004 (IACAPAP, 2006). IACAPAP’s document itemizes basic ethical principles;
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addresses rights of both children and their parents/legal caregivers; reviews consent
and assent; and addresses topics including confidentiality, potential exploitation,
sexual encounters, honesty, involuntary treatment, gifts from patients or industry,
presentation of patient material in publications and professional meetings, research
ethics, multidisciplinary collaboration, and the association’s guidelines for its
acceptance of financial support.
The initial efforts and subsequent revisions noted in these various
declarations and guidelines are a function of circumstances and influences that
change over time. The American Academy of Child and Adolescent Psychiatry’s
(AACAP) Code of Ethics serves as an example. Promulgated initially in 1980,
revised slightly in 2007 and greatly in 2009, the Code reflects changes in medical
knowledge, modes of clinical practice, payments for services, understandings of
psychological dynamics, and practices of the pharmacologic and manufacturing
industries that evolved over three decades (American Academy of Child and
Adolescent Psychiatry, 2009). The most recent revision addresses, directly and
comprehensively, issues of third-party influence, expectations of publication of all
research study results – positive and negative, conflicts of interest, romantic and/
or sexual entanglements with patients and their families, risks of research with
children, practitioner self-aggrandizement, and expectations that practitioners
will have knowledge of the laws prevailing in the professional’s jurisdiction as
well as tensions that might exist between the law and ethical considerations. As
Beauchamp (2009) notes, “the law is not the repository of our moral standards and
values”. By contrast, codes of ethics are guidelines for professional behavior and
they differ from laws by providing greater flexibility and choices of action. The
codes embody standards of professional conduct and the current AACAP code is an
example of one that clearly, rather than vaguely, indicates preferred behaviors. For
the practitioner who has questions about his or her own or a fellow professional’s
motivations, inclinations or behaviors, consultation with colleagues and referral
to a code’s guidelines are arguably the most useful and potentially helpful options.
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the ethics of endeavors with children. Thus, the individual clinician is expected
to work toward outcomes that would prove best for the child (beneficence), avoid
practices that are likely to cause the child harm (nonmaleficence), grant respect for
the choices and wishes of the individual patient (autonomy) and treat all patients
under care fairly, equally, and with fidelity (justice). This same ethical structure
holds for the creation of administrative approaches designed to provide care and
protection for large groups of children (Sondheimer, 2010). For example, when
planning measures to foster improved mental health efforts in schools (Bostic &
Bagnell, 2001; Brener et al, 2007), provide care for children traumatized by war
(Betancourt, 2011; Panter-Brick et al, 2011), or innovate programs for juvenile
offenders (Holden et al, 2003), it is reasonable to expect that authorities would
design their efforts in such ways that the children experience benefit, are not hurt,
feel respected, and receive help and protection equally.
These sentiments and approaches envision the ideal, and some clinical and
administrative conditions might readily lend themselves to stark and clear right
or wrong choices. But reality generally presents conflicts that exist in shades of
gray. Viewing children along maturational continua is an obvious illustration.
Often, the ethical principles
Thus, what may be beneficial for a 16 year old (e.g., respecting the autonomous employed to pursue
right to refuse treatment) may not be helpful for the recalcitrant seven year old. answers to clinical or
Other gray area dilemmas commonly assert themselves as well. For example, administrative questions
conflict with each other, and
given differing perspectives between child and guardian, to whom does the child a reasoning approach must
psychiatrist defer, without ignoring the concerns of the other? When a group be employed to achieve a
(e.g., a family) wants to pursue an agenda favored by the majority of its members, desirable resolution.
is the minority’s dissenting view (not infrequently that of the child patient) to be
accorded respect, and how? When does the child psychiatrist pay attention to the
needs of an individual patient in the context of limited resources if, from a public
health perspective, attention to the community’s needs could ultimately benefit
a greater number of patients? Often, the ethical principles employed to pursue
answers to such clinical or administrative questions conflict with each other, and a
reasoning approach must be employed to achieve a desirable resolution. Notably,
this process should never imply a pre-ordained outcome.
ETHICAL REASONING
Clinicians usually perform their work with patients without stopping to
question the ethical bases of their actions. This makes perfect sense. The average
child psychiatrist is conscientious, has received adequate training and, over time,
acquired clinical experience, all of which foster the child psychiatrist’s provision
of good care in relatively routine fashion. On occasion, however, the child
psychiatrist is confronted with confusing or unsettling situations that leave the
practitioner feeling uneasy and uncertain as to how to proceed (Sondheimer,
2011). The child psychiatrist’s hesitation or discomfort could be due to, e.g., a
parent’s request to order a urine toxicology screen for her adolescent child while
stipulating that the child not be informed of the test’s purpose; a child’s ambiguous
self-harm verbalization that leaves the child psychiatrist uncertain regarding the
patient’s potential safety; or, an agency’s innocent and appropriate request for
information about a child which, if divulged, might prove injurious to the patient.
When the child psychiatrist consciously focuses on, and does not ignore, his or her
own discomfort, the psychiatrist can use the sense of unease as a salient signal to
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recognize the presence of an ethical dilemma and the need for clear and discerning
thought.
The ethical reasoning process follows a consistent pattern. As ethics “is the
enterprise of disciplined reflection on moral intuitions and moral choices” (Veatch,
1989), perhaps the most important step in the process is the initial recognition of
the presence of ethical conflict and an acknowledgment of the need for a response.
Commonly, this recognition follows the child psychiatrist’s almost instantaneous
affective response of unease or dread, itself followed by a fleeting desire to flee the
problem or to hand responsibility for its solution to a colleague. This response
comes on the heels of the realization that none of the possible options for
intervention stands out as strikingly superior to others, and all potential choices
inherently harbor problems. As soon as the “immature” responses pass, it becomes
incumbent on the child psychiatrist to rationally examine the matter. Several The ethical reasoning
approaches are useful. In other than extreme situations calling for immediate process follows a
consistent pattern... The
action, the child psychiatrist should temporize, ask questions, obtain information, resolution often proves to
and delay choosing an ultimate clinical or administrative option. The psychiatrist be the least harmful, but not
is encouraged to reflect on the personal values he or she employs in the reasoning necessarily the seemingly
process. Self-inquiry can lead to cognizance of the roles played by the child optimal
psychiatrist’s upbringing, education, and nonprofessional personal experiences, for
better or worse, in his or her considerations of the dilemma. Third, consultation
with colleagues is often helpful. While the problematic matter may be new to the
child psychiatrist, it is likely to have been encountered by colleagues or addressed
in the professional literature. Further, it may help to include the patient and
other pertinent principals in the discussion of the ethical conflict, in order that
they contribute responsibility for the outcome. Finally, after employing the above
stratagems, the child psychiatrist should consider relevant choices and possible
consequences, while performing risk/benefit analyses on all. The four core afore-
mentioned ethical principles, and the guidelines provided by the child psychiatrist’s
national and international codes of ethics, can aid in arriving at an ultimate choice
of action. This resolution often proves to be the least harmful, but not necessarily
the seemingly optimal.
SAFETY
Primum non nocere – above all do no harm – is a cardinal tenet of proper
medical practice (Smith, 2005). Translating its application to psychiatric care, this
fundamental rule emphasizes that the child psychiatrist’s paramount concern is the
safety of the child (patient). For example, the depressed child recently engaged in
suicidal behaviors, whose self-harm ideation continues unabated, is best cared for
in a psychiatric institution that provides close and constant supervision, despite
the actual and implied infringements on the youngster’s autonomy and freedom
of movement. Another child, who is depressed but not suicidal, would likely
benefit from outpatient care while living at home with his or her family. In both
scenarios safety must be addressed as the primary concern, but the respective
potential threats to well-being are differentiated, resulting in treatment provision in
dissimilar settings. Parenthetically, ethical child psychiatric practice would require
that the practitioner be fully aware of the legal protections available to the child
that are operative in the practitioner’s jurisdiction, in order that infringements on
the child’s rights are kept to a minimum.
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prevailing stigma associated with mental illness, led to a sizable number of vocal
proponents of diagnostic nihilism. In addition, the opprobrium earned by the
misuse of psychiatric diagnoses for political purposes (e.g., the former Soviet
Union’s creation and employment of the novel diagnosis of “sluggish schizophrenia”
in order to forcibly hospitalize and treat political opponents of the regime against
their will) highlighted on an international scale the need for a considerably more
rigorous diagnostic consensus (Wilkinson, 1986).
The last 30 years, however, have witnessed consensual agreement by
psychiatric researchers on progressively more rigorous approaches to groupings of
observed phenomena. These have led in turn to more carefully defined diagnostic
categories. Close collaboration between the consultants producing editions of the
International Classification of Diseases (ICD) and subsequent DSM volumes has
been the rule, leading to considerable compatibility between these two “official”
versions of psychiatric diagnoses (Sartorius et al, 1993). Thus, the diagnostic
process has undergone a transformation permitting collaborators on transnational
studies to more comfortably assume that study subjects from countries other than
their own satisfy the same inclusion and exclusion criteria. Cautions remain,
however, regarding inadequate sensitivity to culture-bound variables (Belfer &
Eisenbruch, 2007; Van Ommeren, 2003).
Rigorous diagnostic criteria permit the development of treatments that
are tailored to specific diagnoses. When used in this fashion – for the good of
the patient – the diagnostic process clearly satisfies a cardinal ethical principle.
However, the potential problems of “labeling” and stigma remain as possibly
harmful to the child (Pescosolido et al, 2007). The practitioner has little control
or influence over how people, other than immediate family, might misuse this
information. Particularly in the current era of electronic transmission a diagnosis
theoretically could attach to an individual “forever”, and relatively unsophisticated
societies could become fearful of and devalue a child carrying a psychiatric
diagnosis. Ultimately, it is the child psychiatrist’s responsibility to provide an
accurate assessment and diagnosis in order to better the patient’s condition; follow
procedures guarding the confidentiality of written materials; and contribute to Child psychiatrists should
be mindful of various
the education of local societies concerning the prevalence of mental disturbance,
influences that could play
prognostic accuracy, treatment efficacy, and the need for familial and community roles in the diagnostic
support (Rosen et al, 2000; Thara et al, 2001). process, while maintaining
awareness that their efforts
In recent years, the US has witnessed a striking increase in the incidence will significantly impact the
of childhood autistic and bipolar disorders. While it appears that, in both cases, near- and possibly longer-
these increases are due to a combination of closer scrutiny and greatly expanded term futures of their child
patients.
diagnostic definitions of these disorders, these developments remind that scientific
progress does not occur without struggle, controversy, conflict and mistakes
(Angell, 2011; Carey, 2007; Kim et al, 2011; Moreno et al, 2007). In the course of
proposed and revised definitions, some children might receive a diagnosis in error
while others may benefit from expanded criteria. In addition, increased awareness
of the diagnoses of childhood ADHD and bipolar disorder in the international
domain may be related to heightened professional education and sensitization of
practitioners to these disorders, promoted in part by pharmaceutical companies.
Their efforts might well be motivated by the desire to provide benefit to a previously
undetected but substantial number of affected children; that the companies
stand to gain financially from the marketing of relevant medications in new and
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psychotherapy are both provided in tandem, in contrast to just one or the other,
though the ability to provide the two is conditional on the presence of available
resources and personnel (The MTA Cooperative Group, 1999; March et al, 2004).
Not infrequently, ethical concerns about somatic and verbally-mediated
treatments are approached as if they present dissimilar dilemmas when, in fact,
similar concerns apply to both. They each have the potential to produce benefit
or harm; risk/benefit analyses should precede the choice of either or both; the
potential for uncalled-for clinician aggrandizement is inherent to the provision
of either; and the inept provision of the one or the other could easily cause harm.
Psychotropic medications, electroconvulsive therapy, and complementary or
“natural” medicines all may directly impact developing brain structure, cerebral
neurotransmitter receptor complexes, and other body organ systems. The more
immediate potential side effects are well-recognized, but the possibility of unleashing
long-term ill effects is unclear. Similarly, beneficial or poor psychotherapeutic care
is likely to have obvious positive or negative near-term psychological impact, while
the long-term effects on psychological functioning, via cognitive incorporation of
the experience, is difficult to determine.
Off-label prescribing of medications is common in child psychiatry practice
due to the paucity of relevant child-based studies (Baldwin & Kosky, 2007;
Bucheler et al, 2002 ; Efron et al, 2003; Hugtenburg et al, 2005). Its consequent
potential for benefit or harm is uncertain and variable. Examples include alpha-
agonists used as second-line treatments for ADHD; neuroleptics used to treat severe Off-label
disruptive behavioral presentations; and the use of lithium, anticonvulsants, and Off-label prescribing
neuroleptic medications in the treatment of vastly increased numbers of patients means prescribing a
diagnosed, in the recent past, with bipolar disorder of childhood. Similarly, medication for a condition
or age group or using a
the application of a single psychotherapeutic modality for a range of disorders;
form of administration
difficulties in psychotherapy provision due to a diminished emphasis in training (e.g., oral, parenteral) not
(Tucker et al, 2009); focus on the individual patient at the expense of the family or formally approved by the
vice versa; and incorporation of corporal rather than structured restraint methods appropriate regulatory
agencies (e.g., FDA,
(even in the context of cultural approval of the former) are all examples of verbally- EMEA). This may vary from
and environmentally-mediated therapeutic impediments or approaches that could country to country.
have deleterious impact on some children while nevertheless benefitting others. Off-label prescribing of
The innovations and the liabilities contribute to the development of the field medications is common in
by adding to its knowledge base, as they underscore the need for ever-improved child psychiatry practice
training and expansion of the treatment armamentarium. Simultaneously, they due to the paucity of
relevant child-based
highlight the limits of the profession’s expertise and the need to rein in diagnostic studies. Its consequent
and treatment hubris. potential for benefit or harm
is uncertain and variable.
In addition to remedies for diagnosed psychiatric illness, preventive treatment
approaches warrant comment (Layne et al, 2008; Sanders, 2002; Silverman et al,
2008). While numerous studies describe treatments of post-traumatic disorders
in children, stress inoculation training was designed to block post-traumatic stress
responses by its introduction in advance of anticipated stress-inducing situations.
Studies describe teacher-mediated group interventions, guided by the instruction
of child psychiatrists and other mental health professionals, that employ the stress
inoculation training goals of fostering resiliency and psychological strength in
groups of children who formerly experienced trauma en masse (Wolmer et al,
2003). While these studies raise an ethical concern, i.e., the withholding of a
putatively therapeutic intervention for students comprising the control groups, it
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appears that child psychiatry involvement in the training of the educators clearly
created benefits for the treated youngsters. When preventive and potentially
therapeutic undertakings are performed in this manner, larger numbers of children
are likely to obtain benefit than would otherwise be impacted in after-the-fact
one-to-one care. This approach adheres to the ethical principle of social justice,
i.e., by providing benefit to the many in essentially equal fashion. It also provides
a clear contrast, in the child setting, for the ethical thought underlying public
health models of care with the more traditional perspective of care provision for
the individual.
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CONFIDENTIALITY
Ordinarily, individuals are accorded privacy rights, implying that they control
ownership of their personal information. When such material is communicated
to physicians in the course of evaluation or treatment, the physician is ethically
(Winslade, 1978) and legally (Simon, 1987) obligated to regard the information
as confidential, not to be revealed to anyone without the patient’s, i.e., the owner’s,
permission. Such professional behavior is respectful of a patient’s autonomy, and
avoids the harm (nonmaleficence) that would easily ensue, directly to the patient
and indirectly to the therapeutic relationship, should a deliberate breach occur.
Maintenance of confidentiality under all circumstances, however, is not an
inherent good – such rigid devotion to the concept could conceivably cause harm.
Several matters warrant consideration. First, differences between adult and child
cognitive abilities suggest that adults have achieved a cognitive maturity that children
only attain following continuous maturation through adolescence. Thus, children
are perceived as lacking the breadth of understanding presumably available to adults
– in the current instance, a solid understanding of confidentiality rights and their
possible limits. Consequently, just as children, using identical reasoning, cannot
legally consent to treatment, only their adult guardians can consent to the release of
children’s confidential information to third parties. Second, children’s psychiatric
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and desires of the family’s or clan’s adults. In these families, the notion of a child’s
confidentiality rights may therefore experience great challenge. For example:
“Anything my child wants to say can be said, and must be said, with me present –
we have nothing to hide from each other.” Directly confronting such a stance by
trumpeting confidentiality rights is likely to end in a failure to persuade. Rather,
acknowledgement of the parent’s desire for pertinent information while promoting
the potential benefits stemming from respect of individual autonomy, in a model
that emphasizes the inclusion of all family members, is more likely to result in
the most efficacious and beneficent care for the child. In contrast to differing
families, a related study, determining the responses of psychiatrists in three
countries to confidentiality scenarios, revealed no significant differences between
the practitioners (Lindenthal et al, 1985).
RESEARCH
Because children cannot give consent by themselves, research involving
young people poses particular ethics challenges. Notably, there has been a growing
appreciation that it is in children’s best interests that good-quality research is
undertaken – the lack of evidence about the effectiveness of many treatments in
the young has already been highlighted and extrapolating to children results found
in trials conducted in adult populations is not necessarily valid. To obviate this
problem some governments (e.g., the US) provide financial incentives (e.g., by
extending the patent period of a drug) if research in children is undertaken. This
notwithstanding, research in young people needs to carefully adhere to ethical
principles and requirements because of the risks of exploitation. These principles
are spelled out in a variety of documents anchored on the Nuremberg Code (which
contains research ethics principles for human experimentation set as a result of the
Nuremberg Trials following the Second World War) and the 1974 Declaration of
Helsinki (Chapter J.7 in this book describes in some detail the implications for Click on the picture to access
IACAPAP’s declarations on
research of the United Nations Convention on the Rights of the Child, particularly ethical practice
in low income countries and in communities enduring war or civil strife).
The IACAPAP’s Declaration of Berlin (2004) – Principles of Ethics in
Child and Adolescent Mental Health (revised in Melbourne, 2006) – states that
“Informed consent to being a research subject should be based on the following
Principles:
• It is essential that clinical research involving human subjects is dedicated
to promoting health
• The well-being of the research subject has priority over the interests of
science and society
• The performance of a research project involving human subjects
should be based on a clearly written proposal that is approved by
an independent ethical committee which includes representatives of
parents and the law
• Participation is voluntary. Any subject can refuse or discontinue
participation without pressure, penalty or loss of benefit
• Children and adolescents may not have the capacity to give informed
consent to being research subjects. However, their assent must be
obtained. Assent should take into account the age, maturity and
Ethics A.1 18
IACAPAP Textbook of Child and Adolescent Mental Health
Ethics A.1 19
IACAPAP Textbook of Child and Adolescent Mental Health
Assent
Assent means (Committee on Bioethics of the American Academy of Pediatrics, 1995):
• Helping children gain a developmentally appropriate understanding of the nature of
their illness
• Explaining what they can expect (good and bad) with the treatment
• Evaluating children’s understanding of the situation, including whether they are being
inappropriately pressured, and
• Seeking an expression of the child’s willingness to accept the treatment
In the case of participation in research, if children do not have a choice and their refusal
or dissent does not count, it should not be pretended that a requirement for assent is to
provide a choice. Children need to know if they do or do not have a choice. A requirement
for assent protects children from psychological or other harm. Children benefit from knowing
what will happen, having a say and being listened to even though they do not have the final Click on the picture to access
authority to make decisions. Seeking assent also respects the child as a person. Part of that “Understanding Consent in
is to provide opportunities for children to develop autonomy. However, assent by itself is not Research Involving Children:
sufficient to authorise participation in research. The ethical Issues”
Dissent
Means that children’s objections and distress are taken into account even when the child is
incapable of taking part in discussions or deciding. In the case of participation in research
trials, dissent does not function only at the point of enrollment. Dissent can be about a child
wanting to withdraw from research.
Ethics A.1 20
IACAPAP Textbook of Child and Adolescent Mental Health
POTPOURRI
As ethical thinking undergirds the structure and practice of child and
Authorship
adolescent psychiatry in its entirety, the range of subjects potentially available for
discussion is vast. The most salient have been addressed, and the topics that follow, The International
discussed in brief, are open to investigation in much greater detail. Committee of Medical
Journal Editors (2006)
Conflicts of interest
explains that authorship
Third party influence has received considerable media attention in the should be based on all
recent past, stemming primarily from the efforts of the pharmaceutical industry to the following criteria:
promote sales of its products, via overt and subtle subsidies and other inducements • Substantial
to physicians (Schowalter, 2008). Such external attempts at influence are exerted contributions to the
as well by health insurance providers, school system personnel, governmental study’s conception
agencies, guardians, colleagues, and financial investors. Internal competing and design or
loyalties can stem from interpersonal rivalries, relationships, and intellectual acquisition of data
passions, resulting in biased rather than dispassionate judgments (Walter et al, or their analysis and
2010). Commonly, these conflicts emerge in research and publication contexts as interpretation
well as interpersonal. In all instances, the child psychiatrist is obligated to prioritize • Drafting the article or
the welfare of the patient above the other interests competing for attention. The revising it critically;
child psychiatrist’s internal conflicting impulses are best handled via transparency, and
honesty, notification, disclosure, self-examination and self-scrutiny. The acid • Approval of the final
test is putting oneself in the patient’s place and examining the matter from that draft.
perspective (Brewin, 1993). ‘Guest’, ‘honorary’ or
‘gift’ authorship are all
Teaching, training and enforcement
considered unethical.
The teaching of ethics is mandated by residency training accrediting A guest author is one
bodies (Dingle & Stuber, 2008). Topics commonly reviewed include advocacy, who is knowingly
consent/assent, agency, autonomy, research concerns, boundaries, confidentiality, listed as an author to
practitioner relationships with health care providers and industry, and the influence reviewers or
relationship and distinctions between ethics and the law (Sondheimer, 1998). to seek some benefit or
professional favor.
Conflicts of interest
Conflicts of interest may be inevitable for clinicians because of the multiple
responsibilities and relationships that are part and parcel of medical practice. Being subject
to competing interests, however, is not necessarily unethical. Maintaining ethical practice is
determined by how one handles them. Knowledge of professional standards, recognition of
potential conflicts and appropriate disclosure are key steps in this process.
Research funded by the pharmaceutical industry reported in psychiatric journals has
been steadily increasing. Moreover, positive outcomes are reported much more often in
trials so funded (78%) than in those without industry sponsorship (48%) or those financed
by a competitor (28%) (Kelly et al, 2006). The obvious issue arises as to the extent to which
industry-funded research influences findings and to what degree one can trust such work.
Conflicts of interest are not restricted to drug trials. For example, The Lancet published
in 1998 a study which suggested a link between autism and the measles-mumps-rubella
(MMR) vaccine. The report sent shockwaves around the globe as well as frightening
parents and medical practitioners. As a consequence, MMR vaccination rates in England
declined by 10% in the following 5 years while cases of measles almost quadrupled.
A journalist later established that the principal author had not disclosed that the Legal
Aid Board had commissioned him to determine, for a sizable fee, if evidence sufficed to
support a legal action by parents of children allegedly harmed by the vaccine. The Lancet
subsequently retracted the article and the UK’s General Medical Council found the lead
author unfit to practice. Subsequent research has conclusively refuted any link between the
vaccine and autism (Demicheli et al, 2005).
Ethics A.1 21
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Ethics A.1 22
IACAPAP Textbook of Child and Adolescent Mental Health
Ethics A.1 23
IACAPAP Textbook of Child and Adolescent Mental Health
the same, they simply are garbed in novel fashions. In addition to the technologies’
heuristic use to child psychiatrists in daily administration, education, research
and clinical practice, they offer specific benefits for patients, e.g., the opportunity
for pervasive developmentally disordered spectrum children, socially awkward
and fearful, to engage socially with others electronically rather than face to face
(Panyan, 1984). For many such youngsters, these communications provide a sense
of comfortable engagement and, for some, lead to later meetings in person with
their contacts. Similarly, many computer programs provide assistance to children
with learning and communication disorders.
As with all new technologies, however, they are also open to misuse.
Bullying of children by peers is a millennia-old problem, but the perpetrator of
the past could always be readily identified. With the advent of current technology,
by contrast, cyberbullying permits anonymous harassment of unsuspecting and
vulnerable peers, commonly leading to considerable distress and the occasional
front-page news article following the suicide of a bullied or “outed” youngster (Boyd
& Marwick, 2011). Preventive and post-incident interventions have been created
in response but, given children’s immature understanding of consequences and
the anonymity afforded by electronic communications, these malicious behaviors
are likely to continue in a world that currently contains 800 million Facebook
members. Psychiatric ethics requires child psychiatry practitioners to be aware of
these developments, the potential of electronics to be used for both good and ill,
the need to advocate and care for those who have suffered, to educate communities
concerning potential benefits and dangers, and to aid in the implementation of
relevant school-based intervention programs.
CONCLUSION
Child and adolescent mental health professionals, whether located in
well-to-do, poverty-stricken, or middle-class areas or countries, share the same
responsibilities – to advocate and provide care for youngsters, commonly the
least protected and most vulnerable age group, independent of locale. Ethical
considerations, principles, and the ways of thinking about dilemmas, whether
arising in clinical, administrative or research contexts, remain the same, independent
of locale as well. Available resources in these locales differ markedly, however,
resulting in different resolutions to these dilemmas in different geographic settings.
The fundamental ethical goals of providing protection and beneficial interventions
to children remains the overarching societal and professional expectation of the
child psychiatrist. This chapter, focusing on such basic matters as assent, dissent,
diagnosis, treatment, confidentiality, and research, coupled with a look at recent
developments in the field, has hopefully provided useful food for thought about
ethical matters which impact on child and adolescent mental health practitioners,
independent of their country of citizenship.
Ethics A.1 24
IACAPAP Textbook of Child and Adolescent Mental Health
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